Warts (Verruca Vulgaris): Pathophysiology, Clinical Features, Diagnosis, and Management

Close-up of a skin lesion being examined with a dermatoscope lens

Published on

August 31, 2026

| Last Reviewed on

August 31, 2026

Verruca vulgaris lesions, commonly known as warts, are caused by various strains of human papillomavirus (HPV) transmitted via direct person-to-person contact. Most non-genital warts stem from specific viral subtypes:

Flat Cutaneous Warts: HPV-3, HPV-10
Common Warts: HPV-2, HPV-7
Plantar Warts: HPV-1, HPV-2, HPV-4

While certain mucosal HPV types (such as HPV-16 and HPV-18) are highly oncogenic, the HPV subtypes responsible for cutaneous warts do not carry malignant potential.

Clinical Concept: “Watch and wait” therapy, where no treatment is prescribed, is often appropriate because most warts self-resolve within 12 to 24 months.

1. Clinical Presentation & Subtypes

Cutaneous warts present in distinct clinical patterns depending on the site and viral strain:

Common Warts: Present as hyperkeratotic papules with rough, irregular surfaces, ranging in size from 1 mm to 1 cm. They occur most frequently on the hands and feet.
Plantar Warts: Begin as small papules that progress to deep, well-defined, round lesions with a rough keratotic surface. They are often surrounded by smooth calloused skin and can cause significant pain due to inward, deep growth.
Flat Warts: Smooth or slightly hyperkeratotic, flat or slightly elevated lesions. They can present in small clusters or coalesce into hundreds of lesions, most commonly on the face, hands, and shins.

Differential Diagnosis: Warts that are exceptionally large or refractory to standard therapies may represent verrucous carcinoma, a rare carcinoma arising on the plantar surface. Other differential diagnoses include actinic keratosis, cutaneous squamous cell carcinoma (SCC), lichen planus, molluscum contagiosum, and seborrheic keratosis.

2. Diagnostic Approach

Diagnosis of verruca vulgaris is primarily clinical based on visual appearance and physical examination. Lesion biopsy is indicated only when the diagnosis is uncertain or to rule out malignancy in atypical, refractory lesions.

3. Treatment Options

Active intervention is warranted if warts interfere with function (such as painful plantar lesions), or if they are cosmetically problematic and fail to self-resolve. Surgical excision is rarely indicated.

Treatment	Instructions for Use	Comments & Clinical Notes
Liquid Nitrogen (Cryotherapy)	Apply to achieve a thaw time of 20 to 45 seconds. Administer 2 freeze-thaw cycles every 2 to 4 weeks until the lesion resolves.	Yields good cosmetic results. Can be painful and often requires multiple treatment sessions.
Keratolytic Agents (Cantharidin®, Occlusal-HP®, DuoFilm®, Duoplant®, Virasal®, etc.)	Apply as directed until lesions resolve. For plantar warts, pare down the lesion, then apply a 40% salicylic acid plaster, changing every 5 days.	Well tolerated. Often requires long-term therapy (up to 6 months or more) with multiple cycles needed.
Podophyllum Resin (Podofilox)	Apply three times a week for 4 to 6 weeks.	Skin irritation is common; multiple treatment cycles are frequently required.
Tretinoin	Apply twice daily (BID) to flat warts for 4 to 6 weeks.	Requires consistent, daily treatment for optimal clinical outcomes.
Imiquimod (Aldara®)	Frequency and duration of application depend on wart location.	Acts as an immunomodulation agent; associated with a low rate of wart recurrence.
Laser Therapy	Used to dissect lesions.	Requires 4 to 6 weeks for tissue granulation. Best reserved for treatment-resistant warts.

References

1. Long MC. Warts (verrucae). In: Bope ET, Kellerman RD, eds. Conn’s Current Therapy 2019. Philadelphia, PA: Elsevier; 2019:1041–1044.